FORM NO. 12C
[See rule 26B]
Form for sending particulars of income under section 192(2B) for the year ending 31st March,…………………

1. Name and address of the employee  
2. Permanent Account Number
3. Residential status     
4. Particulars of income under any head of income other than "Salaries" (not being a loss under any such head other than the loss under the head "Income from house property") received in the financial year                                                                                              Rs.
(i) Income from house property
(in case of loss, enclose computation thereof)
(ii) Profits and gains of business or profession
 (iii) Capital gains         
 (iv) Income from other sources                               Rs.
(a) Dividends   
(b) Interest      
(c) Other incomes (specify)
                                                                         TOTAL           Rs.
5. Aggregate of sub-items (i) to (iv) of item 4    
6. Tax deducted at source [enclose certificate(s) issued under section 203]       
 Place…………….
Date………...                                                                         Signature of the employee
Verification
I,…………….., do hereby declare that what is stated above is true to the best of my knowledge and belief.
Verified today, the……………..day of
Place…………….
Date………………..                                                               Signature of the employee